Estimation of depression, anxiety and serum cortisol in patients with oral lichen planus, leukoplakia and oral submucous fibrosis

Stress and anxiety may be found in patients with oral submucous fibrosis (OSMF), oral leukoplakia (OL) and oral lichen planus (OLP). Cortisol, sometimes referred to as the "stress hormone," has been employed as a stress predictor. Therefore, it is of interest to estimate the levels of depression, anxiety and serum cortisol and establish correlation between them in patients with OL. OLP and OSMF. There were 240 patients, aged 20 years to 45 years, who were divided into four categories (OL, OSMF, OLP and control) of 60 patients apiece. In the supervision of a psychiatrist, the Hamilton Depression Rating Scale (HAM D) and Hamilton Anxiety Rating Scale (HAM (A) questionnaires were filled out. Five millilitres of venous blood were extracted using standard aseptic technique, and all of the samples were examined for serum cortisol level. Anxiety and depression was found in subjects of OL, OSMF and OLP at advanced stages. It was inferred that serum cortisol level was statistically correlated with depression and anxiety in patients with OL, OSMF and OLP.


Background:
Stress is defined as a state of physical or emotional strain that might show up as physical symptoms, psychological symptoms, or both [1][2][3].Examples of these symptoms include fatigue, anxiousness, insomnia, and depression.Depression is regarded as "a state of dissatisfaction or sorrow," which is felt occasionally, whereas anxiety can be described as "an emotional condition that includes feeling uneasy, discomfort, and apprehension about any known or unknown threat" [4][5][6].Stress weakens our resistance to infection through two different processes, which aids in the progression of disease [7-9].The primary one is a biological process that involves the synthesis of cortisol regulated by the "hypothalamic-pituitary-adrenal (HPA) axis."The other type is the cognitive mechanism that encourages harmful habits like smoking, drinking, eating poorly, not brushing your teeth, and engaging in other parafunctional activities [10][11][12].As a consequence of these behaviors, there is a decline in oral health, which leads to a range of oral disorders [13][14][15].People acquire habits over time, such as smoking, consuming gutka, tobacco chewing, betel nut chewing, and pan chewing, which might result in the occurrence of potentially malignant illnesses (PMDs).Among the most prevalent oral mucosal disorders in humans are oral submucous fibrosis (OSMF), oral leukoplakia (OL) and oral lichen planus (OLP) [16][17][18].These conditions should be further studied as psychological disorders.According to some reports, as many as forty percent of cancer patients experience a considerable degree of misery [19][20][21].Cortisol, sometimes referred to as the "stress hormone," has been employed as a stress predictor.The primary glucocorticoid in humans, cortisol affects vascular response, metabolic processes, immunoregulation, mental processing, and personality [22][23][24].The significant link between psychiatric problems and chronic physical ailments have been the subject of much research in recent years.Nonetheless, there is still a dearth of information on psychological morbidity in OL, OLP and OSMF [13][14][15][16][17][18].Therefore, it is of interest to estimate the levels of depression, anxiety and serum cortisol and establish correlation between them in patients with OL.OLP and OSMF.

Methods and materials:
Patients who visited in the institution outpatient facility were included in the study.There were 240 patients, aged 20 years to 45 years, who were divided into four categories of 60 patients apiece (Table 1).Patients who met the following requirements were accepted into the study: they had to be ready to participate, be older than eighteen, and have an established record of smoking, using smokeless tobacco, chewing areca nut products, and smoking.PMDs of OMF, OL, and OLP that have been clinically as well as histopathological confirmed.Patients who were hesitant to participate in the trial or who were receiving current therapy for one of the disorders considered in the study were excluded from the study.Individuals with physiological situations like gestation or systemic illnesses as well as patients with impaired health, particularly those with mental health disorders were excluded.Individuals with periodontal illnesses or oral mucosal lesions were also excluded.The patients underwent routine examination procedures.In the supervision of a psychiatrist, the Hamilton Depression Rating Scale (HAM D) and Hamilton Anxiety Rating Scale (HAM (A)) questionnaires were filled out [17].An early blood test to measure cortisol levels was planned for each patient.Five millilitres of venous blood were extracted using standard aseptic technique, and all of the samples were examined right away.Using the ROCHE COBA E 411 electrochemiluminescence immunoassay, the serum cortisol level was determined.Serum cortisol levels in the range of 138 to 600 nmol/L were considered normal.

Statistical analysis:
Excel was used to tabulate the gathered data.Version 25.0 of the Statistical Package for Social Sciences (SPSS) for Windows was used to analyze the data (IBM Corp, Armonk, NY).There was usage of descriptive statistics like mean, standard deviation, and percentage.All parameter distributions were examined for normality using the Shapiro-Wilk test.Using the independent samples t test, variables with normal distributions in two groups were compared.One way analysis of variance with post hoc was used to compare the means of more than two groups.When data adhere to the premise of homogeneity of variances, Tukey's HSD is used; when data do not, the post hoc Games-Howell test is used.The Fisher's Freeman-Halton or Chi square tests compared frequencies, by cross tabulation precisely.The degree and direction of the relationship between anxiety and depression and blood cortisol levels were evaluated using Spearman's rank correlation.It was deemed statistically significant when P < 0.05.Sex and age coincided, healthy controls free of any indications or symptoms of the conditions listed above 60 Results: The serum cortisol level increased as the anxiety level raised from normal too mild to moderate.The serum cortisol level was statistically correlated with the level of anxiety in all study participants (Table 2).4).The findings were significant statistically.The serum cortisol level increased as the depression level raised from normal, mild, moderate, severe and very severe.The serum cortisol level was statistically correlated with depression levels (Table 5).It was also observed that number of study participants with serum cortisol levels corresponding to mild, moderate, severe and very severe depression levels was maximum in patients with OL followed by OLP and OSMF.The findings were significant statistically (Table 6).7).The depression score was maximum in patients with OL followed by OLP and OSMF.The findings were significant statistically.Anxiety and depression was found in subjects of OL, OSMF and OLP at advanced stages.It was inferred that serum cortisol level was statistically correlated with depression and anxiety in patients with OL, OSMF and OLP.

Conclusion:
Anxiety and depression was found significantly in subjects of OL, OSMF and OLP.It was also inferred that serum cortisol level was statistically correlated with depression and anxiety in patients with OL, OSMF and OLP.

Table 3 : Data regarding levels of anxiety study participants of different
cortisol level indicative of mild anxiety level.Similarly, the serum cortisol levels indicative of moderate anxiety was observed in 21 OSMF, 15 OL and 23 OLP patients.Maximum number of patients with mild anxiety level and moderate anxiety level was found in OLP category followed by OSMF category and OL category.The findings were significantly correlated (Table3).

Table 7 : Mean depression score recorded among study participants in different
Anxiety and depression was found in all subjects of OL, OSMF and OLP.